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DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> f) Describe specifically the period over which the activities will be carried out, the frequency <br /> with which the activities will be carried out, and the frequency with which services will be <br /> delivered. Include an implementation timeline. <br /> g) Provide a bulleted list of other agencies, if any, with which your agency <br /> coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) <br /> to be funded. For each, give specific examples of the coordinated/collaborative efforts. <br /> h) Describe what would happen if requested funding is not awarded at all or if a reduced <br /> allocation is recommended. <br /> i) Include any other pertinent information. <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: ® Persons ❑ Households ❑ Units <br /> Program: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 7 13 13 <br /> Female 6 10 10 <br /> Total 13 23 23 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 4 11 11 <br /> American Indian or Alaska Native <br /> Asian 6 4 4 <br /> Caucasian <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Other(Latino) 3 8 8 <br /> Total 13 23 23 <br /> Main Application 5/25/2016 10:17:47 AM P of 20 <br />